SMCMA Physician

Painful Lessons: How San Mateo County is Turning the Tide on Opioid Use

By Jessica Santina

It’s hard to believe, with all the warnings about the opioid crisis, that it all stems back to the simple poppy plant. Back in the 18th and 19th centuries, a deceptively simple substance extracted from poppies seduced and enslaved generations of people. Users were said to fall into the arms of Morpheus—a literary term producing the soothing image of being lovingly protected by the god of dreams against the pains of life.

And for those dependent on its euphoric effects, it may feel that way … at first. Yet modern-day physicians know all too well that there’s nothing soothing about opioid addiction, which can cause mood swings, depression, anxiety, nausea, poor physical coordination, painful withdrawal symptoms and even death. 

Since 2001, when the Joint Commission labeled pain the fifth vital sign, opioid dependence has surged into a full-blown epidemic, particularly in the U.S. While Americans comprise just 4.6 percent of the world’s population, we consume a whopping 80 percent of the global opioid supply and 99 percent of the global hydrocodone supply.

As physicians around the country grapple with exactly what role opioids should play in health care and how to balance pain management with preventing addiction, practitioners right here in San Mateo County are making some positive strides.

Scott Morrow, MD, MPH, MBA, FACPM, practices family medicine at San Mateo Medical Center and has been a health officer with San Mateo County Health System for 26 years. He says the office has conducted intensive data work on the opioid crisis for the last four to five years.

“We do not have the same opioid problems [in San Mateo County] that we’re seeing in other areas of the country, namely the Midwest and Deep South,” Morrow says. “We certainly have an issue and we can do better, but it’s nothing like what people are hearing on the news about these other places. From what I can see, the county’s rate appears to be stable.” 

According to information from the Centers for Disease Control and Prevention, Alabama, Tennessee and West Virginia, respectively, had the nation’s highest numbers of opioid prescriptions per 100 residents, while Hawaii, California and New York had the lowest numbers. And parts of San Mateo County—Redwood City and South San Francisco in particular—had some of the lowest numbers in the state between 2015 and 2016.

What accounts for these differences? A study released last year by the CDC connected higher uninsured and Medicaid enrollment rates, lower educational attainment and higher unemployment rates, among other attributes, to higher rates of opioid prescriptions. Prescription and abuse rates tend to be higher in more rural areas. 

It’s also possible that state- and county-wide efforts among physicians and health care organizations are making an impact.

Sunil Bhopale, MD, FACEP, assistant physician in chief at Kaiser Foundation Hospital in Redwood City, has helped to lead Kaiser Permanente Northern California Opioid Initiative, which included efforts to create a unified set of guidelines for safe opioid use throughout the entire system. Content experts, pharmacists, surgeons, neurologists and other practitioners came together in 2015 to develop a set of recommended guidelines to treat various types of pain. Education modules were led by various physicians to emphasize a standard set of best practices, and electronic medical records (EMRs) were leveraged and improved with better communication among physicians and pharmacists in order to help them share and find information about opioid use—diagnoses and treatment plans—within the system quickly and easily.

“If a patient gets any prescription filled through a Kaiser pharmacy, I can look that up instantly,” Bhopale says. “Doctors are sharing prescribing data among doctors, so if a doctor is prescribing more than others, he or she can share information about why.”

He also explains that Kaiser adjusted its default opioid amounts for prescriptions from 30 pills to 10 or 20. “It’s easier for doctors to be judicious that way,” he says. “Most patients don’t end up taking the full amount of pills anyway.”

Of course, California’s Controlled Substance Utilization Review and Evaluation System (CURES) is undoubtedly playing a major role in helping to curb opioid abuse in the state. The database of Schedule II, III and IV controlled substance prescriptions dispensed in California to assist public health, regulatory oversight and law enforcement agencies is also being called into use at Kaiser as well, says Bhopale.

He adds that education—for both physicians and patients—has been a key aspect of Kaiser’s approach. Physician training programs on patient encounters were instituted to help prepare physicians for potentially difficult discussions with patients who may demand opioid prescriptions. The emphasis has been on listening to patients about their pain, better communication about opioids and their alternatives and better follow-up with patients.

Internal data for Kaiser Northern California indicated a 43 percent drop of opioid prescription numbers within two years of the start the Opioid Initiative in 2016. Bhopale says there have been additional, unexpected benefits as well.

“One of the reasons doctors are concerned about [curbing opioid prescriptions] is patient satisfaction scores,” Bhopale says. “Our scores did not go down. I think what was really reaffirming was that patients want to know that the doctor is doing what he or she thinks is best for the patient, not just handing them a prescription. Just having that conversation about why no opioids or why other things might be better … that makes all the difference.”

Eddie Baddour, MD, chief of emergency medicine for Kaiser Permanente South San Francisco Medical Center, says that patients are overall becoming savvier about opioids, which may be due to increased media attention. 

“I think our community is great, and if we let them know the reason we don’t think it’s in their best interests, most patients are willing to try other medications,” Baddour says. “In fact, many don’t want opioids because they’re aware of the possibilities of addiction.”

Baddour says that within the Kaiser Northern California system, the Emergency Department was a pioneer in identifying opioids as a problem, and that his was one of the first facilities to enforce a rule against offering new opioid prescriptions for chronic or recurrent pain.

“About seven years ago, we came up with a chronic pain letter for patients,” Baddour says. “It explained that we’ll treat for new pain, but for chronic pain, you would need to see your regular doctor. Only one physician should be prescribing narcotics for you—your primary care physician—and he or she should monitor it appropriately.”

Soon all 21 medical centers were implementing these changes, and the results speak for themselves. Baddour says excellent teamwork and communication have led to Kaiser’s success, particularly at his facility. “I think [the success] comes from having all doctors on board, being consistent and accountable and having those difficult conversations up front. We started locally in the ED, we got the medical staff on board, then all the centers in Northern California got on board, and it’s gone well, so everyone’s graph for opioid use has seen a downward turn.”

Lisa Key, MD, MPH, who practices occupational medicine, also at TPMG in South San Francisco, notes that a renewed commitment to determining the best course of pain management to maintain functionality is critical to keeping opioid usage low. 

“One of the challenges is treating it appropriately to control pain but to limit the use to prevent addiction. We work to document actual need and talk to patients about realistic expectations. We tell them opioids are not a panacea, and that the goal is to keep them functional, so if they aren’t, it’s not a successful use and they are quickly weaned off,” Key says. 

She also references a recent study published in the Journal of the American Medical Association that looked at the effects of opioids versus non-opioid medications on pain-related function in patients with chronic back, hip or knee pain. Researchers found that opioid treatment was not superior to non-opioids for improving pain-related function in these cases. Key suggests that a number of alternative pain therapies and treatments often may be more effective than opioids for certain conditions.

“I think it’s important that we are actually utilizing other modalities of treatment to control pain,” she says. “Acupuncture is very effective for chronic pain, as well as physical therapy, myofascial therapy, mindfulness therapy/cognitive behavioral therapy, yoga and Tai Chi. These should be utilized on a more robust basis to minimize use of medications.”

Bhopale adds that a wider range of opioid alternatives are being used in emergency departments and surgery as well. Some examples are local anesthetic injections and a greater emphasis on Early Recovery After Surgery (ERAS) measures, including use of IV acetaminophen instead of opioids to speed recovery and lessen patient disorientation. Other measures include use of ice and heat, massage, early ambulation, physical therapy and other non-opioid medications.

Of course, some physicians simply are adjusting their practices in order to avoid the potential minefield of pain management altogether. One such physician is internist Alexander Lakowsky, MD, MBA, who works alongside his wife, Andra Batlin, MD, at their Burlingame practice, Premier Medical Care.

Lakowsky says that while they’ll assist patients with post-operative pain, they don’t do any chronic pain management. “For that, we refer patients to a pain-management specialist. Complying with requirements puts a strain on our practice because we have to check with the CURES database and confirm the medications are being taken correctly.”

Lakowsky says that while he can’t speak for every practice, he believes the vast majority of primary care doctors in the county would prefer not to have patients taking narcotics at all for chronic pain in their practices, and he knows of several others that also refer these patients out. He explains that for many small practices such as his, combing through codes for prescriptions and consulting databases, though certainly important measures, can be a burden. He’d like to see less of the burden falling on physicians overall.

“It definitely needs to be regulated; the burden just shouldn’t be all on the doctors,” Lakowsky says, citing a recent example in which a simple prescription for a cough syrup with codeine led to a requisite pharmacy call to his office to have him explain why he prescribed it. “The CURES database sets up a cross-check for pharmacists, so in some cases it’s fine to question a prescriber’s decision, but to do it across the board with every prescription puts a burden on us, and it sets up a situation in which physicians won’t prescribe opioids, even if patients need it.”

Dr. Morrow agrees that perhaps there is undue burden being placed on physicians. “We need to make sure [health care] organizations support providers to make recommendations, so it doesn’t always fall on the doctor to say no, if a patient is asking for opioids adamantly.”

Consistency and accountability could definitely be emphasized more heavily during medical training, says Baddour. “When new doctors come on board, their [opioid prescription] numbers may be higher for their first couple of months, so an emphasis on it within education programs would be great.”

A collaborative approach already seems to be delivering results, according to recent data released by the American Medical Association, which cites a notable decrease in opioid prescriptions nationally.

“This is the type of impact that can be achieved when our various specialties, professional societies, policymakers, patients and communities come together to work collectively toward a positive outcome,” says Alex Ding, MD, Past-President of the San Mateo County Medical Association. “We realize there is still a great deal of work to be done, but when we work together with all stakeholders in a productive fashion, real, positive changes can be made.”

Bhopale echoes these sentiments, expressing that he would like to see greater coordination among providers in the county, beyond the Kaiser Permanente system, and he is spearheading efforts to make that happen. He says that although he is pleased by San Mateo County’s relatively low rates of opioid use, he is concerned that it may cause county officials to deprioritize efforts to create county-wide agreements.

“The feeling seems to be that it’s a problem nationally but not so much in our backyard. There’s definitely interest, but not a groundswell like with other issues,” Bhopale says. “We’re doing a good job, we’re lucky, but if we don’t stay ahead of the curve, it’s a slippery slope.”

Jessica Santina is a freelance writer and editor of several publications.